Perceptions of formal pharmacy leadership on the social role of the profession and its historical evolution: A qualitative study

Background

In recent years, pharmaceutical professionalism has been questioned due to the social role of pharmacy, which is ambiguous in the literature. This raises questions about the purpose of the profession among pharmacists, despite the efforts of their professional organizations and formal leaders to consolidate the occupational status of the profession.

Objective

To understand the social role of pharmacy in Brazil through its historical evolution based on the perceptions of formal leaders of the profession.

Methods

A qualitative study was conducted between July 2020 and February 2021 with pharmacists who held leadership positions in formal and professional pharmacy organizations in Brazil. The data obtained from the interviews were submitted to content analysis.

Results

A total of 17 pharmacists participated in this study. The data analyzed presented perceptions about the social role of the pharmaceutical profession in Brazil, which promotes access to health through different means. These include the manager pharmacist, who facilitates access to public health policies; the caring pharmacist, who promotes health education and the rational use of medicines; and the technologist pharmacist, who researches, develops, and promotes access to safe and cost-effective medicines. The interviewees also discussed the evolution of this social role based on influential factors such as legislation, clinical movement, pharmaceutical education, labor market, behaviors, and attitudes of pharmacists.

Conclusion

In this study, pharmaceutical professionalism was conceptualized based on its social role, which should be centered on the patient. Understanding such issues is part of the evolutionary purpose of the profession in Brazil and should be encouraged in the behaviors and attitudes of pharmacists despite the challenges faced by the profession.

At odds: How intraprofessional conflict and stratification has stalled the Ontario paramedic professionalization project

Historically, self-regulation has provided some professions with power and market control. Currently, however, governments have scrutinized this approach, and priorities have shifted toward other mandates. This study examines the case of paramedics in Ontario, Canada, where self-regulation is still the dominant regulatory model for the healthcare professions but not for paramedics. Instead, paramedics in Ontario are co-regulated by government and physician-directed groups, with paramedics subordinate to both. This paper, which draws on interviews with paramedic industry leaders analyzed through the lens of institutional work, examines perspectives on the relevance of self-regulation to the paramedic professionalization project. Participants had varying views on the importance of self-regulation in obtaining professional status, with some rejecting its role in professionalization and others embracing regulatory reform. Because paramedics disagree on what being a profession means, the collective professionalization project has stalled. This research has implications for understanding the impact of intraprofessional relationships and conflict on professionalization projects.

A technical solution to a professional problem: The risk management functions of prognosticators in the context of prognostication post-cardiac arrest

Cardiac arrest (CA) is a major cause of mortality and morbidity globally. Two-thirds of deaths among patients admitted to intensive care units following out-of-hospital CA are due to neurological injury, with most as a consequence of withdrawing life-sustaining treatment, following prognostication of unfavorable neurological outcome. Given the ramifications of prognosis for patient outcome, post-cardiac arrest (P-CA) guidelines stress the importance of minimizing the risk of falsely pessimistic predictions. Although prognosticator use is advocated to this end, 100% accurate prognosticators remain elusive, therefore prognostication P-CA remains pervaded by uncertainty and risk. Bioethical discourse notwithstanding, when located within a wider socio-cultural context, prognostication can be seen to present risk and uncertainty challenges of a professional nature. Such challenges do not, however, subvert the medical profession's moral and ethical prognostication obligation. We interpret prognosticator use as an attempt to manage professional risk presented by prognostication P-CA and demonstrate how through performing "risk work," prognosticators serve professional functions, mediating tension between the professional duty to prognosticate, and risk presented. We draw on sociological analyses of risk and uncertainty, and the professions to explicate these (hitherto less enunciated) professional risk management functions of prognosticators. Accordingly, the use of prognosticators is conceived of as a professional response - a technical/scientific solution to the problem of professional risk, inherent within the P-CA prognostication process.

On the professional authority of quality engineers and the gaps in their epistemic and organizational authority

The authority of quality engineers as a profession is a contested issue that relates both to the occupation’s internal regulation and to the professional status of quality engineers within the organizations for which they work. In this article, we examine the professional authority of quality engineers from both these perspectives. The issue is addressed first through a conceptual framework, followed by a presentation of an empirical study in which seven experienced quality professionals were interviewed and completed questionnaires. We focus on the situation in Israel as a case study, but our insights are relevant to quality engineers throughout the world. We demonstrate limitations with regard to both (1) the epistemic authority (expertise) of quality engineers vis-à-vis their status as a professional association and (2) the organizational authority of quality engineers vis-à-vis their organizational role as quality managers. These limitations can be attributed to the occupation’s status as a semi-profession; the level of expertise required is not fixed or uniform; the authority of a quality engineer varies from one organizational structure to another. In addition, individual quality engineers are accorded different levels of influence, usually at the discretion of their employing organizations. For these reasons, the expertise of quality engineers as a professional group remains an open issue.

The dynamics of TCAM integration in the Indian public health system: Medical dominance, countervailing power and co-optation

Hierarchies of power among healthcare professionals are well documented, nonetheless, power remains neglected, understudied and under-theorised in health systems analysis and policy discussions, especially in the domain of Traditional, Complementary and Alternative Medicine (TCAM). Sociological and public health scholarship has documented the persistence of medical dominance in the health system, theorised as the limitation, subordination, exclusion and incorporation of other professions. This paper explores how interprofessional power dynamics shape the integration of TCAM into Indian primary healthcare centres, as part of a nationwide policy of TCAM integration and medical pluralism implemented since 2005. We conducted interviews (n = 37) with health system administrators, nurses, pharmacists, TCAM and biomedicine doctors, and observed day-to-day activities of primary healthcare centres for six months in Odisha state, India. Thematic analysis enabled the identification of themes and exploration of sub-themes. The analysis revealed multilayered forms of medical dominance within the primary healthcare system and identified multiple sites where everyday power is mobilised. Biomedicine practitioners exercised authoritative power and restricted TCAM doctors' access to facility-level resources, i.e. financial and workforce support, which inhibited the integration policy implementation. Significantly, TCAM doctors were 'ordered' to practice biomedicine at primary healthcare centres, which was beyond the scope of the integration policy. However, TCAM doctors were also able to exercise countervailing power in their day-to-day activities in the primary healthcare centres and sought to assist patients' health behaviour change through their authoritative knowledge about 'how to live a healthy life'. The health system actors involved in policy implementation hold a range of forms of power specific to the circumstances, influencing the integration processes. We explain these dynamics in relation to existing theories of medical dominance and countervailing power, while introducing a previously unreported dimension of dominance: 'co-optation', which enrols TCAM practitioners in the practice of biomedicine.

How professional actions connect and protect

Below we provide responses to the ongoing debate sparked by Mirko Noordegraaf’s intervention in suggesting that we are moving toward forms of ‘connective professionalism’. Critics in this debate have objected to Noordegraaf in a number of ways. Some object to a conflation of ideal types and empirical description. Others assert that Noordegraaf suggests a staged process of moving from protective to connective types of professionalism does not ring true; that we can finds forms of connection and protection in contemporary professionalism and in professional action. Our companions in this issue (Alvehus, Avnoon, and Oliver) suggest that greater connectiveness also permits new forms of protection as part of professionalism. Our short essays contribute to the Noordegraaf debate by focusing less on professionalism and more on how forms of professional action lead to mechanisms of connection and protection.

A Draconian Law: Examining the Navigation of Coalition Politics and Policy Reform by Health Provider Associations in Karnataka, India

A comprehensive picture of provider coalitions in health policy making remains incomplete because of the lack of empirically driven insights from low- and middle-income countries. The authors examined the politics of provider coalitions in the health sector in Karnataka, India, by investigating policy processes between 2016 and 2018 for developing amendments to the Karnataka Private Medical Establishments Act. Through this case, they explore how provider associations function, coalesce, and compete and the implications of their actions on policy outcomes. They conducted in-depth interviews, document analysis, and nonparticipant observations of two conferences organized by associations. They found that provider associations played a major role in drafting the amendments and negotiating competing interests within and between doctors and hospital associations. Despite the fragmentation, the associations came together to reinterpret the intentions of the amendments as being against the interests of the profession, culminating in a statewide protest and strike. Despite this show of strength, provider associations only secured modest modifications. This case demonstrates the complex and unpredictable influence of provider associations in health policy processes in India. The authors' analysis highlights the importance of further empirical study on the influence of professional and trade associations across a range of health policy cases in low- and middle-income countries.

The governmentality of nursing professionalization in advanced liberal societies

In Western countries, the occupational discipline of nursing is undergoing processes of professionalization. Although professionalization offers an appealing perspective on occupational advancement, it is an ambiguous process, especially in the context of ongoing reforms of advanced liberal states. More specifically, there is a confusing relationship between the professionalization of nursing and the state. This relation is underexamined in theories of nursing professionalization. Instead of seeing the state and professions as two distinct spheres, this article highlights their interconnectedness. It argues that nursing professionalization can be understood as a strategy of advanced liberal governmentality. Through an empirical analysis of the professionalization of Dutch nursing from a Foucauldian perspective, it shows how the appeal to ‘professionalism’ functions as a disciplinary mechanism that produces forms of advanced liberal ‘(bio)power’. This generates academic and practical questions, since nurses—the largest group of healthcare professionals—have distinctive relations with their patients, who regard them as ‘independent’ and ‘caring experts’. Furthermore, it sheds light on the academic debate about the reconfiguration of professionalism by showing how certain ‘professional’ reconfigurations are not only unavoidable but unavoidably (bio)political as well.

Red tape and psychological capital: a counterbalancing act for professionals in street-level bureaucracies

Assuming that red tape is inevitable in institutions, and drawing on positive organizational behavior, we compare the impact of individual psychological capital on the ability of street-level bureaucrats (SLBs) with different professional backgrounds to work within the confines of red tape. The two SLB professions investigated here are nurses and local government employees; and the work outcomes of interest to this study are well-being and engagement. The findings show that red tape has a different impact on each professional group but, encouragingly, they also indicate that psychological capital has a compensatory effect. Implications include nurses requiring more psychological resources than local government employees to counteract the negative impact of red tape. A practical implication for managers is that, if perception of red tape in organizations is set to increase or to stay constant, enhancing the psychological capital of professionals in SLB roles, through specific interventions, may be beneficial to professionals and organizations alike.

Between contestation and collaboration: The internal dynamics of multidisciplinary accounting firm responses to institutional pressures

The colonization of adjacent professional fields has been considered as crucial to understand the success and influence of large accounting firms, such as the Big 4. Yet, given the complexities of managing different professional groups, remarkably little is known about the internal dynamics behind large multidisciplinary accounting firms’ external responses to institutional pressures. In this article, we show how exogenous coercive pressure, such as regulation (in this case Dutch accountancy regulations), not only affect the day-to-day work of accountants, but also that of non-accountants such as tax advisors. From the perception of the tax advisors who confront regulations which are not ‘theirs’, we show how their internal responses evolve and tread a fine line between contestation and collaboration with their colleague accountants/auditors. Using a boundary work perspective, we examine this shift in responses and explain how tensions between professional groups may be reduced. Overall, our study not only furthers our insights into the internal dynamics behind professional service firms’ external responses, but also sheds light on why professional groups stay on board despite unfavorable internal conditions.

Developing and validating the Japanese version of professional attitude scale for nurses

Aim

We developed and psychometrically tested the Japanese version of the Professional Attitude Scale for Nurses (PASN‐J).

Background

Nurses must recognize the importance of their professionalism; therefore, it is critical to quantitatively measure nurses’ professional attitudes.

Introduction

This instrument validation study was designed to generate an itemized scale and examine its content validity/psychometric testing using a sample of Japanese nurses.

Methods

Based on a trait approach focusing on the characteristic traits of the nursing profession, a 59‐item draft scale was generated. During November 2017, 2657 nurses from 29 facilities in Japan were surveyed. The questionnaire included demographics, the 59‐item draft scale, and a self‐report scale of nurses’ professional behaviour and nursing practice ability. Using exploratory and confirmatory factor analyses, we evaluated the construct, criterion‐related, concurrent, and known‐groups validity, and reliability of the PASN‐J.

Results

Data from 1716 participants were analysed. The analyses yielded a 38‐item, 3‐factor scale that adequately fit the data. PASN‐J scores were positively correlated with nurses’ professional behaviour and nursing practice ability.

Conclusion

The 38‐item PASN‐J has good reliability and validity, making it useful for measuring the current condition of nursing professionalism and evaluating nursing education. Implications for Nursing and Health Policy: This scale can evaluate nursing education and promote nurses’ professionalism. The PASN‐J will help identifying the elements of undergraduate nursing education that require further emphasis. Additionally, the PASN‐J could facilitate the development of nursing policies to promote professional development in nurses. Ultimately, evaluating nursing education with the PASN‐J enhances nurses’ professional attitudes and subsequently improves their quality of nursing, nursing efficiency and patient outcomes.

Connective professionalism: Towards (yet another) ideal type

In this essay, four leading scholars provide critical commentary on an article entitled ‘Protective or Connective Professionalism? How Connected Professionals Can (Still) Act as Autonomous and Authoritative Experts’ (Noordegraaf, 2020, Journal of Professions and Organization, 7/2). Of central concern to all four commentators is Noordegraaf’s use of ideal types as a heuristic device to make his case and capture historical change over time. While some question the usefulness of ideal types, others question Noordegraaf’s use of them. The commentators raise additional concerns, especially the limited attention to variations across professions, geographic regions, and limited attention to social–historical contexts.

A framework for medical power in two case studies of health policymaking in India and Niger

Medical professionals influence health policymaking but the power they exercise is not well understood in low- and middle-income countries. We explore medical power in national health policymaking for child survival in Niger (late 1990s-2012) and emergency medicine specialisation in India (early 1990s-2015). Both case studies used document review, in-depth interviews and non-participant observation; combined analysis traced policy processes and established theoretical categories around power to build a conceptual framework of medical power in health policymaking. Medical doctors, mainly specialists, utilised their power to shape policy differently in each case. In Niger, a small, connected group of paediatricians pursued a policy of task-shifting after a powerful non-medical actor, the country's president, shifted the debate by enacting broad health systems improvements. In India, a more fragmented group of specialists prioritised tertiary-level healthcare policies likely to benefit only a small subset of the population. Compared to high-income settings, medical power in these cases was channelled and expressed with greater variability in the profession's ability to organise and influence policymaking. Taken together, both cases provide evidence that a concentration of medical power in health policymaking can result in the medicalisation of public health issues.

Competing Logics and Healthcare Comment on "(Re) Making the Procrustean Bed? Standardization and Customization as Competing Logics in Healthcare"

This paper offers a short commentary on the editorial by Mannion and Exworthy. The paper highlights the positive insights offered by their analysis into the tensions between the competing institutional logics of standardization and customization in healthcare, in part manifested in the conflict between managers and professionals, and endorses the plea of the authors for further research in this field. However, the editorial is criticized for its lack of a strong societal reference point, the comparative absence of focus on hybridization, and its failure to highlight structural factors impinging on the opposing logics in a broader neo-institutional framework. With reference to the Procrustean metaphor, it is argued that greater stress should be placed on the healthcare user in future health policy. Finally, the case of complementary and alternative medicine is set out which – while not explicitly mentioned in the editorial – most effectively concretizes the tensions at the heart of this analysis of healthcare.